TY DALLAS MANGUM Physician Assistant License verification

Business Entity

NOT RENEWED

License Type

Physician Assistant

Description

PHYSICIAN ASSISTANT CONTROLLED SUBSTANCE

License Number

38*****05

License Status

NOT RENEWED

Business

First Name

Middle

DALLAS

Last Name

MANGUM

Business Name

TY DALLAS MANGUM

Original Issue Date

12/21/2021

Effective Date

12/21/2021

Expiration Date

03/01/2024

City

EVANSTON

State

Zip

60202

County

COOK

Delegated Controlled Substance Schedule

II III IV V

Ever Disciplined

LastModifiedDate

02/05/2025